• Child
• health services
• international
• policy
• public health

One of the most commonly used public health measures of progress in child survival is the under-5 mortality rate. This rate conveys some useful information provided that it has been calculated appropriately and accounted for threats to internal and external validity. However, the under-5 mortality rate lumps together the contribution of neonatal and post-neonatal mortality with deaths in the 1–4 year period. The significant drawback of this is that it obscures our understanding of the most appropriate child survival strategies as children move beyond their first year of life.

Death in childhood is heavily skewed towards the first days of life. A recent appraisal of under-5 deaths in 187 countries estimated that over 40% of the 7.7 million under-5 deaths in 2010 occurred in the first 27 days, and a further 30% occurred from the 28th to the 364th day of life.1 Aetiological analyses show that sepsis, birth asphyxia, congenital abnormalities and preterm complications tend to drive neonatal deaths, and a variety of infectious conditions (notably pneumonia and diarrhoea) are major drivers of deaths during the post-neonatal period.2

A paper by Jagnoor and colleagues in this issue of the journal provides direct estimates of under-5 injury mortality for India (see page 151).3 In a direct illustration of the masking effect of aggregating mortality in infancy with the 1–4 year period, the authors find a ninefold increase in the proportion of mortality attributable to injury between infancy and the 1–4 year age category. They also show that drowning is the most common …